| 6400.112(a) | An unannounced Fire Drill was not held for the month of September 2020. | An unannounced fire drill shall be held at least once a month. | 1. What was done immediately to correct the specific issue cited?
A. On 10/15/20, during a site record review, the Regional Director discovered that an unannounced Fire Safety training for the home was not held in the month of September. A fire drill was conducted at 9:48 a.m. on that same day, 10/15/20. Staff were trained on the importance of unannounced fire drill on that same day, 10/15/20. What education and training has been provided to staff?
B. In addition to specific training on fire drills, all staff received annual Fire Safety training on 12/22/2020. During the weeks of 1/4/21 & 1/11/21, staff will be trained on the new process and accompanying tracker to ensure required drills are conducted and properly documented each month.
What specific change will be made?
During monthly staff meetings, House Managers will review, with staff, the monthly Fire Drill Log and the importance of conducting the required monthly unannounced fire drills and bi-annual overnight fire drills.
Who (by title) will make the change?
The House Manager will review the importance of conducting drill and dates of all monthly staff drills at monthly meetings.
2. What specific change will be made? What system was implemented to prevent violation from recurring?
A. During monthly staff meetings, House Supervisor will review the most recent Fire Drill(s) and related documentation and remind staff of the Fire Drill needs for current month.
B. In addition to existing protocols and documentation related to Fire Drills and Fire Safety, a new process and tracker was developed to ensure that all DSP Staff and Management staff for the home review documentation for Fire Drills on a monthly basis, prior to due dates to ensure the site is on track, drills were conducted correctly and reports are accurate and complete.
C. An new annual monthly fire drill tracker (in addition to currently used logs) will be filed in the site¿s Fire Drill / Fire Safety binder. The tracker is accessible to all staff and serves as a reminder to conduct drills, vary fire ¿locations¿ and use of exits (if more than one exits exists) for each drill, conduct overnight drills for required number of months.
D. After each fire drill, staff will complete new ¿Annual Monthly Fire Drill Tracker,¿ along with Fire Drill Report and submit to House Supervisor. House Supervisor will review each tracker after each drill and initial and date tracker to indicate it was reviewed. Program Director (PD) will review the tracker by the end of the third week of each month and initial and date the tracker. By the 3rd week, PD will ensure that required drills were conducted or monitor to ensure that drills are conducted in the remaining week.
E. By the 5th of each month, the PD will send the Fire Drill Reports, from previous month, to QI, along with a copy of the Tracker. (See attached process and tracker)
C. What education and training has been provided to staff?
In addition to specific training on fire drills, all staff received annual Fire Safety training on 12/22/2020. During the weeks of 1/4/21 & 1/11/21, staff will be trained on the new process and accompanying tracker to ensure required drills are conducted and properly documented each month. |
12/22/2020
| Implemented |